Gene therapy

Abstract

The present invention relates generally to polypeptides or nucleic acids for use in the treatment, management, retardation of progression or normalisation of development of an iduronate-2-sulfatase (IDS) deficiency and/or Mucopolysaccharidosis type II (MPS II) in an individual, wherein the polypeptides comprise iduronate-2-sulfatase (IDS) tethered to a tandem repeat of Apolipoprotein E (ApoEII) or the nucleic acids comprise an iduronate-2-sulfatase (IDS) gene sequence tethered to a tandem repeat of the Apolipoprotein E (ApoEII) gene sequence. The invention also relates to haematopoietic stem and progenitor cells (HSPCs) transduced by such nucleic acids for use in therapies.

Claims

1. A nucleic acid comprising an iduronate-2-sulfatase (IDS) gene sequence and a tandem repeat of an Apolipoprotein E (ApoEII) gene sequence, further comprising an intervening linker sequence located between the IDS sequence and the ApoEII sequence, wherein the intervening linker sequence comprises the sequence according to SEQ ID No. 4 or a derivative sequence having at least 95% homology to SEQ ID No. 4.

2. The nucleic acid of claim 1, wherein the IDS sequence comprises a codon-optimised sequence of the wild-type IDS sequence.

3. The nucleic acid of claim 1, wherein the IDS sequence comprises the sequence according to SEQ ID No. 1 or SEQ ID No. 2 or a derivative sequence having at least 90% homology to SEQ ID No. 1 or SEQ ID No. 2, or the ApoEII sequence comprises one or more sequences according to SEQ ID No. 3 or a derivative sequence having at least 95% homology to SEQ ID No. 3.

4. The nucleic acid of claim 1, wherein the nucleic acid is incorporated in a gene therapy vector.

5. The nucleic acid of claim 4, wherein the vector is a lentiviral vector.

6. The nucleic acid of claim 1, wherein the nucleic acid is transduced in one or more haematopoietic stem and progenitor cells (HSPCs).

7. A combination of the nucleic acid of claim 1 and one or more haematopoietic stem and progenitor cells (HSPCs), wherein the nucleic acid is capable of transducing the HSPCs.

Description

DETAILED DESCRIPTION OF THE INVENTION

(1) Aspects and embodiments of the present invention will now be illustrated, by way of example, with reference to the accompanying figures. Further aspects and embodiments will be apparent to those skilled in the art. All documents mentioned in this text are incorporated herein by reference.

(2) FIG. 1 shows the generation and validation of a novel blood-brain barrier-crossing IDS enzyme in vitro. (a) Schematic representation showing pCCL lentiviral vectors encoding for the codon-optimised human IDS gene, or the human IDS gene followed by a flexible linker and the ApoEII peptide sequence as a tandem repeat. Both lentiviral vectors are driven by the human CD11b promoter. (b) Schematic representation and sequences of the invariant linker and ApoEII tandem repeat added at the C-terminal of the IDS gene. (c) Graphs showing intracellular IDS enzyme activity measured in a human microglial cell line (CHME3) after transfection with 2 μg plasmid DNA of either LV.IDS or LV.IDS.ApoEII for 24 hours, and measured 48 hours post-transfection. n=3. (d) Secreted IDS enzyme activity measured in transfected human microglial cells (CHME3) with 2 μg plasmid DNA of either LV.IDS or LV.IDS.ApoEII for 24 hours, and measured 48 hours post-transfection. n=3one-way ANOVA, **=p<0.01 vs. non-transfected. (E) Uptake of IDS or IDS.ApoEII from media into bEND.3 cells after 24 hours, n=3 wells/condition (F) Receptor-mediated uptake of IDS or IDS.ApoEII through M6PR or LDLR 24 hours after blocking with 7.5 mM M6P or 50 μg/ml human recombinant apoE for 4 hours, n=3 wells/condition. Data are shown as mean±SEM, two-way ANOVA, *=p<0.05, **=p<0.01, ****=p<0.0001 comparisons are indicated by brackets;

(3) FIG. 2 shows that LV.IDS and LV.IDS.ApoEII improve brain-specific IDS activity and express supra-physiological levels of active IDS in peripheral organs. (a) Schematic representation of the stem cell gene therapy strategy. Busulfan-conditioned 6-8-week-old MPS II mice were transplanted with 4×10.sup.5 lin-HSCs transduced with LV.IDS or LV.IDS.ApoEII at an MOI of 100, or 1×10.sup.7 total bone marrow cells. (b) Graph showing vector copy number and (c) Graph showing IDS enzyme activity were measured in transduced HSCs from colony-forming unit assays at transplant. (d) Graph showing donor chimerism in WBCs was measured by flow cytometry at 4-weeks post-transplant in all transplanted mice. (e) Graph showing vector copy number and (f) Graph showing IDS enzyme activity were measured in organs taken at 8 months of age, including BM, WBC/plasma, spleen and brain, from control and treated mice (n=6). (g) Graph showing VCN to enzyme activity correlation in individual mice in bone marrow, WBC/plasma, spleen and brain (n=6). (I) Graph showing IDS enzyme activity were measured in heart from control taken at 8 months of age. (j) Plasma clearance rate of IDS or IDSApoEII following injection into WT mice. (M) Correlation between plasma IDS enzyme activity and IDS protein measured by ELISA. Levels of lysosomal enzyme β-hexosaminidase activity were analysed in the (N) plasma, (O) spleen and (P) brain of 8-months old mice. Data are shown as mean±SEM, one way-ANOVA, *=p<0.05, **=p<0.01, ***=p<0.001, ****=p<0.0001 vs. MPSII, other comparisons are indicated by brackets;

(4) FIG. 3 shows LV.IDS.ApoEII correct cognitive abnormalities in MPS II mice, and all transplants ameliorate coordination and balance. (a) Schematic representation of the Y-maze test. Mice are placed in the centre and allowed to explore freely for 10 minutes. (b) Graph showing spontaneous alternation in the Y-maze was measured in control and treated mice at 8 months of age, and (c) Graph showing the total number of entries was recorded as a proxy measure of locomotor activity. (d) Representation of the accelerating rotarod. (e) Graph showing 8-months-old control and treated mice were trialed 3 times on the accelerating rotarod for a maximum of 300 seconds (4-4 rpm over 300 seconds);

(5) FIG. 4 shows LV.IDS.ApoEII normalises cytokines associated with neuro-inflammation in 8-months-old mice. (a)-(c) Graphs showing cytokine bead arrays measuring MIP-1α, MCP-1, IL-1α and RANTES were performed on whole brain lysate of 8-months-old mice using flow cytometry (n=6). (d) Graph showing MCP-1(CCL2). (e) Graphs showing total relative amounts of total HS. (f) compositional disaccharide analysis of HS from control and treated mice (n=6) analysed from brain samples. (g) Representative images of 30 μm sections of the motor cortex (M2) and striatum stained with isolectin B4 (ILB4) to identify activated microglia, 40×. Four 30 μm sections per mouse of the (h) cortex and (i) striatum were counted for the number of ILB4-positive cells (from approx. 0.26 mm to −1.94 mm from bregma), n=3/group. Scale bar: 50 μm. Data are shown as mean±SEM, one-way ANOVA, *=p<0.05, **=p<0.01, ***=p<0.001, ****=p<0.001 vs. MPSII, other comparisons are indicated by brackets;

(6) FIG. 5 shows WT-HSCT, LV.IDS and LV.IDS.ApoEII normalise gross skeletal abnormalities in MPS II mice. (a) X-ray images of control and treated MPS II mouse craniums at 8 months of age. (b) Graph showing Zygomatic arch widths (c) Graph showing humerus widths. (d) Graph showing femur widths were analysed using ImageJ software (n=5-11); Cytokine bead arrays measuring (E) MCP-1, (F) MIP-1α and (G) RANTES and were performed on liver lysates of 8-months-old mice using flow cytometry, n=4-6. Gene expression of (H) Nppb and (I) Myh7 in hearts of control and treated MPS II animals (WT n=3, MPS II n=4, WT-HSCT, LV.IDS and LV.IDS.ApoEII n=6). (J) IDS-specific IgG antibody titers were measured in plasma. (K) Total IgG antibodies against IDS were determined in plasma samples by ELISA (Pos. control n=1, neg. control n=6, LV.IDS/LV.IDS.ApoEII n=6). Data are shown as mean±SEM, one-way ANOVA, *=p<0.05, **=p<0.01, ***=p<0.001, ****=p<0.0001 vs. MPSII;

(7) FIG. 6 shows primary accumulation of heparan sulfate and its sulphation patterning in the brain is entirely normalized to WT levels using LV.IDS.ApoEII, not LV.IDS. (A) Total relative amounts of HS and (B) compositional disaccharide analysis of HS from control and treated mice were analysed from brain samples, n=6/group. (C) Representative images of 30 μm brains sections of the motor cortex (M2), caudate putamen (both approx. −0.46 mm from bregma), hippocampus (CA3) and amygdala (both approx. −1.22 mm from bregma) from control and treated mice stained with NeuN (neuronal nuclei; green) and LAMP2 (lysosomal compartment; red), n=6/group, 40×, nonlinear adjustments were made equally in all images to reduce background; gamma 0.72, input levels 0-190. Scale bar: 50 μm. Data are shown as mean±SEM, one-way ANOVA, *=p<0.05, **=p<0.01,***=p<0.001, ****=p<0.0001 vs. MPSII, other comparisons are indicated by brackets;

(8) FIG. 7 shows LV.IDS.ApoEII normalizes astrogliosis in 8-months-old MPS II mice. (A) Representative images of 30 μm brains sections of the motor cortex (M2, approx. −0.46 mm from bregma), caudate putamen (approx. −0.46 mm from bregma), hippocampus (CA3) and amygdala (both approx. −1.22 mm from bregma) from control and treated mice stained with GFAP (glial fibrillary acidic protein; green) and LAMP2 (lysosomal compartment; red), n=6/group, 40×, nonlinear adjustments were made equally in all images to reduce background; gamma 0.72, input levels 0-190. Scale bar: 50 μm. GFAP immunofluorescence was quantified in the (B) cortex and (C) amygdala of 8-months-old MPS II mice, n=3/group, AU: arbitrary units. Data are shown as mean±SEM, one-way ANOVA, *=p<0.05, **=p<0.01 vs. MPSII, other comparisons are indicated by brackets;

(9) FIG. 8 shows a schematic diagram illustrating the proposed mechanism of action of the IDS.ApoEII enzyme in MPS II mice that allows IDS.ApoEII to correct the cognitive phenotype in MPS II mice. The ApoEII residue allows IDS to remain active for longer in plasma, leading to longer circulation time and higher chances of crossing into the CNS, whilst unmodified IDS is quickly degraded to an inactive form. Within the brain, corrected microglia derived from the bone marrow secrete IDS or IDS.ApoEII in similar levels but IDS.ApoEII uptake is more efficient and couple with improved stability, leads to better correction of primary storage and neuro-inflammation; and

(10) FIG. 9 shows graphs and immunofluorescent staining images showing increased plasma stability and enhanced uptake by brain endothelial cells via multiple mechanisms. (A) Plasma clearance of IDS protein measured in MPS II mice injected with 12 ng of total IDS enzyme at 1, 10 and 30 minutes post-injection, n=2/group. (B) Correlation between plasma IDS enzyme activity and IDS protein measured by ELISA. (C) FITC-dextran uptake into bEND.3 cells. (D, E) Immunofluorescent staining for LDLR (D) or LRP1 (E) in bEND.3 cells. (F) Uptake of IDS or IDS.ApoEII produced by CHME3 cells added to growth media of bEND.3 cells grown in monolayer culture for 24 hours. n=2 independent experiments, with 3 wells/condition. (G) Uptake of IDS or IDS.ApoEII produced by CHME3 cells added to growth media of bEND.3 cells grown in transwell culture for 24 hours. n=3 independent experiments, with 2 wells/condition. (H) Percentage transcytosis to the basal layer of bEND.3 cells from G. (I) Receptor-mediated uptake of IDS or IDS.ApoEII after 24 hours, following heparinase treatment of the cell layer or blocking with 7.5 mM M6P or 50 μg/ml human recombinant ApoE for 1 hour prior to enzyme addition. n=3 wells/condition. Data are mean±SEM, one-way ANOVA or T-test as appropriate, *=p<0.05, **=p<0.01, ***=p<0.001, ****=p<0.0001 vs. MPS II.

EXAMPLE 1

(11) Experiments were conducted to transduce a vector containing a codon optimised IDS with haematopoietic stem and progenitor cells (HSPCs) which were subsequently tested in a mouse model for the expression of IDS and in particular to assess the amount of IDS passing through the blood brain barrier.

(12) Expression Vectors

(13) Human IDS cDNA (SEQ ID No. 2) was adapted so as to form codon-optimised IDS cDNA (coIDS) (SEQ ID No. 1) and synthesised using GeneArt technology (ThermoFisher, Paisley, UK) and cloned into the third-generation LV pCCL.sin.cPPT.hCD11b.ccdB.wpre using Gateway cloning to create pCCL.sin.cPPT.hCD11b.IDS.wpre). An additional vector containing the cDNA sequence (SEQ ID No. 3) of the brain-targeting peptide sequence ApoEII as a tandem repeat (LRKLRKRLLLRKLRKRLL) (SEQ ID No. 7) was inserted downstream of the codon-optimised human IDS cDNA using the long invariant linker cDNA sequence (SEQ ID No. 4) so as to provide a LGGGGSGGGGSGGGGSGGGGS linker (SEQ ID No. 8) (32). Plasmids were codon-optimised and synthesised using GeneArt technology and cloned as previously described into a 3.sup.rd-generation lentiviral backbone. The amino acid sequence for human IDS cDNA (SEQ ID No. 2) is referenced as SEQ ID No. 6, wherein the amino acid sequence for coIDS cDNA (SEQ ID No. 1) is referenced as SEQ ID No. 5. The resultant amino acid sequences for both human IDS cDNA and coIDS cDNA are the same.

(14) Transfection and Cross-Correction

(15) Human microglial cells (CHME3) were transfected with 2 μg of plasmid CD11b.IDS or CD11b.IDS.ApoEII DNA using 7.5 mM high-potency linear polyethylenimine (pH 7.4, MW 40,000, Polysciences Inc., Warrington, Pa., USA) and 150 mM NaCl. Cells were collected 48 hours post-transfection in RIPA buffer (150 mM NaCl, 1% Triton-X100, 0.5% sodium deoxycholate, 0.1% SDS, 50 mM Tris, pH 8) and incubated on a shaker at 4° C. for 30 min, followed by centrifugation at 14,000 rpm, 4° C. for 20 minutes. Cell lysates were collected and stored at −80° C. Media supernatants were collected 48 hours post-transfection and centrifuged at 1,000 rpm, 4° C. for 10 minutes to remove cell debris and stored at −80° C.

(16) LV Production and Titration

(17) LV was produced (25) by transient transfection of HEK 293T cells with pMD2G, pΔ8.91gag/pol, LV plasmid (24, 25, 34, 35) and 7.5 mM polyethylenimine (40 kDa, Polysciences, Warrington, Pa., USA) (36). Lentiviral vector particles were concentrated by centrifugation at 21,191 g for 150 minutes at 4° C., resuspended in formulation buffer (PBS, 1 mg/ml human serum albumin, 5 μg/ml protamine sulphate, 40 mg/ml lactose, pH 7.2). EL4 mouse lymphoma cells (ATCC TIB-39; ATCC, Manassas, Va., USA) were transduced with three dilutions of concentrated LV and collected 72 hours later. Genomic DNA was extracted using GenElute Mammalian Genomic DNA Miniprep kit (Sigma-Aldrich, Poole, UK). The number of integrated viral genomes per cell was determined by quantitative PCR using a standard curve generated by dilutions of genomic DNA from an EL4 cell line clone containing 2 copies 2 integrated copies/cell of pHRsin.SFFV.eGFP.att.wpre (ALS EL4 eGFP 2.2) (24). A primer and probe set against wpre (TAMRA) were used as previously described (24, 25) and standardised against rodent gapdh (VIC) (Applied Biosystems, Paisley, UK).

(18) Mice and Transplant Procedures

(19) Female heterozygous for the X-linked allele were obtained from Prof. Joseph Muenzer (University of North Carolina at Chapel Hill, N.C., USA) and bred with wild-type C57BL/6J males (Envigo, Alconbury, UK) to obtain wild-type males and females, and affected hemizygous males and carrier females. MPSII were backcrossed onto the PEP3 CD45.1 congenic background (B6.SJL-Ptprc.sup.aPepc.sup.b/BoyJ) to distinguish donor and recipient cells as previously described (24). WT littermates were used as controls throughout.

(20) Total bone marrow mononuclear cells from MPSII mice were isolated from femurs and tibias, and lineage depleted using the murine lineage cell depletion kit (Miltenyi Biotec, Bisley, UK) according to the manufacturer's instructions. Cells were resuspended at 1×10.sup.6 cells/ml in X-Vivo-10 media (BioWhittaker) containing 2% bovine serum albumin and stimulated using 100 ng/ml murine stem cell factor, 100 ng/ml murine fms-like tyrosine kinase-3 and 10 ng/ml recombinant murine interleukin-3 (Peprotech, Rocky Hill, N.J., USA) for 3 hours prior to transduction with a lentiviral vector for 20-24 hours at a multiplicity of infection of 100.

(21) Six-to-eight-week-old mice housed in individually ventilated cages were myeloablated using 125 mg/kg Busulfan (Busilvex; Pierre Fabre, Castres, France) in five daily doses (25 mg/kg/day) via intraperitoneal injection. Prior to myeloablation, mice received acidified water (pH 2.8), irradiated food and mash. Within 24 hours of receiving the last injection of busulfan, mice were injected with 3-4×10.sup.5 lineage-depleted transduced haematopoietic stem cells through the lateral tail vein. For wild-type transplants (WT-HSCT), mice received 1-2×10.sup.7 untransduced total bone marrow cells.

(22) Chimerism Analysis Using Flow Cytometry

(23) Engraftment of donor haematopoietic stem cells was assessed at 4 weeks post-transplant in peripheral blood. Cells were stained with anti-mouse CD45.1-PE (donor HSCs), CD45.2-FITC (recipient HSCs), CD3-Pe-Cy5 (T-cell), CD19-APC-Cy7 (B-cell) and CD11b-Pe-Cy7 (macrophage/microglia) (BD Pharmingen, Oxford, UK) in a 5% solution of ToPro3 Iodide (ThermoFisher Scientific, Paisley, UK) and analysed on a BD FACS Canto II flow cytometer (BD).

(24) Sample Processing

(25) At 8 months of age, mice were anesthetized and transcardially perfused with 37° C. phosphate buffered saline to remove blood from organs. One brain hemisphere was fixed in 4% paraformaldehyde for 24 hours, transferred to a 30% sucrose, 2 mmol/1 MgCl2/phosphate-buffered saline solution for 48 hours before freezing at −80° C. Pieces of brain, spleen, heart, kidney, muscle and liver were snap-frozen on dry ice and stored at −80° C. For IDS enzyme activity assays, samples were homogenised and sonicated in homogenisation buffer (0.5 mol/l NaCl, 0.02 mol/l Tris, 0.1% Triton-X100, pH 7-7.5) before centrifugation at 14,000 rpm at 4° C. for 30 minutes. Bone marrow samples were collected by flushing one tibia and femur with 1 ml 2% FBS/PBS, filtered using a 70 μm filter and lysed using red blood cell lysis buffer (150 mM NH4Cl, 10 mM KHCO3, 0.1 mM EDTA, pH 7.2-7.4). Supernatant was collected and stored at −80° C. Genomic DNA used for organ VCN analysis was extracted using GenElute Mammalian Genomic DNA Miniprep kit.

(26) IDS Enzyme Activity

(27) IDS enzyme activity was measured in a two-step protocol using the fluorescent substrate MU-aldoA-2S (Carbosynth, Compton, UK) and laronidase (Aldurazyme, Genzyme) as the second step substrate as previously described (37). The amount of starting material was standardised to 20 μg of total protein for plasma, 40 μg for liver, spleen and bone marrow, and 60 μg for brain using a BCA assay (ThermoFisher).

(28) Preparation of Purified Glycosaminoglycans

(29) Soluble brain fractions were collected and processed as previously described (38). Briefly, brain tissue was homogenised mechanically and Pronase-treated (1 mg/tissue) in 3 ml PBS for 4 hours at 37° C.30 μl of TritonX100 was added to each sample for a 1% final concentration and incubated for an hour at room temperature prior to a second addition of 1 mg of Pronase for 4 hours at 37° C. Samples were loaded onto a pre-equilibrated DEAE-Sephacel column and hyaluronan was removed by washing the column with 50 ml of 0.25M NaCl/20 mM NaH.sub.2PO.sub.4.Math.H.sub.2O (pH 7). GAGs were eluted with 5 ml 1.5M NaCl/20 mM NaH.sub.2PO.sub.4.Math.H.sub.2O (pH 7), desalted using a PD10 column (Amersham, GE Healthcare) and freeze-fried.

(30) Heparinase Digestions of HS and DS Followed by AMAC-Labelled Analysis

(31) HS chains were digested using 5 mlU each of heparinase I, II and III (Seikagaku, Tokyo, Japan) in 100 μl of 0.1M sodium acetate and 0.1M calcium acetate (pH 7). Resulting disaccharides were freeze-dried, re-dissolved in 20 μl of 0.1 M 2-aminoacridone (AMAC) in 85% Me.sub.2SO/15% acetic acid (v/v) and incubated at room temperature for 20 minutes. 20 μl of NaBH.sub.3CN was added to each sample and incubated overnight at room temperature. AMAC-labelled disaccharides were separated by reverse phase high-performance liquid chromatography using a Zorbax Eclipse XDB-C18 column (2.1×500 mm, 3.5 μm) (Agilent Technologies, Stockport, UK).

(32) Cytometric Bead Array (CBA)

(33) Levels of IL-1α, MCP-1, MIP-1α and RANTES were measured in whole brain extracts at 8 months of age (n=6/group) using BD Cytometric Bead Array (CBA) Flex Set kits (BD Biosciences, Oxford, UK) (40). Analysis was performed on a FACS Canto II flow cytometer (BD). Identification of the singlet bead population was performed using the FSC vs SSC plot, and each individual cytokine bead was separated using APC and APC-Cy7, with cytokine levels measured using PE. The results were exported and analysed using FCAP Array software (BD). Brain protein concentrations were obtained using the BCA assay and cytokine levels were standardised to protein level for each sample.

(34) Behavioural Analysis

(35) Rotarod

(36) The rotarod test was used to evaluate motor coordination and balance at 32 weeks of age as previously described with minor modifications (41). Male mice (WT, n=16, MUT, n=12, treatment groups n=12-16) were trained on the rotarod (Ugo Basile, Varese, Italy) across three training trials (4 rpm for 120 seconds; 4 rpm for 300 seconds; 4-40 rpm over 300 seconds) with a 30 minute interval between each session. Three test trials were carried out 24 hours post-training. For test trials, the rotarod rotated at an accelerating speed of 4 to 40 rpm over 300 seconds, with a 5 minute rest between each trial. Latency to fall was recorded for all training and test trials, and latency to fall off was calculated as percentage of total trial time.

(37) Spontaneous Alternation

(38) Spatial working memory was assessed in all mice at 32 weeks of age using the spontaneous alternation test (41, 42). Spontaneous alternation was assessed in a single 10-min trial in a Y-maze consisting of three identical arms. The test mouse was placed in the middle of the three arms and allowed to explore freely. Spontaneous alternation was described as successive entries into three arms, in overlapping triplet sets. The effect was calculated as percent alternation=[no. of alternations/(total number of arm entries−2)]×100.

(39) X-Ray Imaging of Live Mice

(40) Control and treated mice were anesthetised using isoflurane and radiographed (45 keV) using the Bruker InVivo Xtreme system fitted with a high sensitivity, back-thinned back-illuminated 4MP, 16-bit, digital CCD camera. X-ray images were analysed using ImageJ software for individual bones widths.

(41) Statistics

(42) Statistical analysis was performed using GraphPad Prism 7 software (La Jolla, Calif., USA). Two-tailed parametric unpaired t-tests were applied for individual group comparisons with significance set at p<0.05. One-way ANOVAs were performed for multi-group analysis followed by Tukey's multi-comparisons test.

(43) Development and In Vitro Validation of Blood-Brain Barrier-Targeting IDS Enzyme

(44) During the experiments, the inventors sought to develop a novel MPS II-specific sulphatase enzyme that was able to efficiently cross the BBB through the use of the LDLR via receptor-mediated transcytosis. Novel lentiviral vectors encoding for human IDS alone, or human IDS linked to the human ApoE receptor-binding region as a tandem repeat, were constructed under the human myeloid-specific CD11b promoter (as illustrated in FIG. 1a).

(45) This sulphatase was modified by adding an invariant flexible linker to the C-terminal of the IDS gene, followed by the codon-optimised sequence of the receptor-binding portion of human ApoE as a tandem repeat (as illustrated in FIG. 1b). Typically, the addition of a linker and peptide can alter protein folding and detrimentally affect enzyme activity.

(46) To verify that the inventive construct still allowed for IDS overexpression and secretion, a human microglial cell line (CHME3) was transfected with plasmid DNA expressing either LV.IDS or LV.IDS.ApoEII. 26-fold and 24-fold increases in cellular activity were observed with LV.IDS and LV.IDS.ApoEII, respectively (as shown in FIG. 1c). More importantly, increases of 84-fold and 81-fold in secreted IDS activity were detected 72 hours post-transfection (FIG. 1d). Notably, this demonstrates that the C-terminal modifications do not negatively impact secretion or expression of the modified IDS enzyme in vitro. A significantly increased uptake of IDS.ApoEII over IDS in mouse endothelial bEND.3 cells after 24 hours (FIG. 1E, 1F) was detected, predominantly, but not exclusively, via M6P receptors (FIG. 1F)

(47) LV.IDS- and LV.IDS.ApoEII-Mediated Stem Cell Gene Therapy Improve IDS Enzyme Activity in the Brain and Express Supra-Physiological Levels of Active IDS in Peripheral Organs

(48) 4×10.sup.5 lineage-depleted haematopoietic stem cells (HSCs) were transplanted from MPS II donors transduced with either LV.IDS or LV.IDS.ApoEII, expressing IDS or IDS.ApoEII, into 16 busulfan-conditioned 6-8 week-old MPS II mouse recipients (as illustrated in FIG. 2a). Unmodified total bone marrow cells were also injected into fully myelo-ablated MPS II recipients, equivalent to an allogeneic stem cell transplant, and are henceforth referred to as WT-HSCT.

(49) IDS activity and vector copy number (VCN) were measured in lineage-depleted HSCs (lin-HSCs) isolated from colony-forming unit (CFU) assays prior to transplant. The experiments demonstrated mean vector copy numbers of 3.1 and 3.8 in the LV.IDS- and LV.IDS.ApoEII-transduced HSCs (as shown in FIG. 2b) and overexpression of IDS enzyme by 124-fold and 152-fold over WT, respectively (as shown in FIG. 2c). These data demonstrate a positive correlation between the number of vector genome integrations and enzyme overexpression in haematopoietic cells. Flow cytometry analysis of peripheral WBCs at 4-weeks post-transplant demonstrated full engraftment of transduced cells into MPS II recipients, achieving between 80-100% of donor CD45.1+ cells (as shown in FIG. 2d).

(50) To assess therapeutic efficacy of this novel gene therapy in MPS II, 6 animals from each group were sacrificed at 8 months of age for biochemical analysis of central and peripheral organs. Vector integrations were detected in total BM, WBCs, spleen and brain, with a significantly lower mean in LV.IDS.ApoEII-treated mice in WBCs only (as shown in FIG. 2e). A small number of animals consistently showed lower VCNs in all organs assessed, but received modified HSCs in separate transplantation procedures. Supra-physiological levels of IDS were observed in BM, plasma and spleen for both LV.IDS- and LV.IDS.ApoEII-treated groups. IDS enzyme activity levels in the brain were also elevated compared to untreated MPS II animals, and are equivalent to between 1.5% and 8% of normal IDS activity in WT brains. The WT-HSCT transplants restored IDS levels equivalent to WT in BM, plasma and spleen only, whilst no noticeable increase in IDS activity was detected in the brain over untreated MPS II animals.

(51) Advantageously, IDS activity in plasma of LV.IDS.ApoEII-treated animals was 3-fold higher than in the LV.IDS-treated group, suggesting potential alterations in enzyme stability and circulation time, secretion or uptake into cells (as shown in FIG. 2f). Furthermore, positive correlations between VCN and IDS enzyme activity levels further suggests that enzyme overexpression is driven by increases in genome integration of the IDS gene (FIG. 2g). However, correlations between WBC VCN and IDS activity in plasma show significant differences between LV.IDS and LV.IDS.ApoEII groups, where low VCN in LV.IDS.ApoEII WBCs results in IDS levels that are higher than in any of the LV.IDS-treated mice, suggesting mechanistic differences in enzyme production, uptake or secretion. Additionally, higher IDS levels in plasma of LV.IDS.ApoEII-treated animals does not yield higher IDS enzyme levels in brain, as enzyme levels in the brain are equivalent in both LV-treated groups (as shown in FIG. 2f). The clearance rate of injected enzyme in plasma was similar between the IDS and IDS.ApoEII groups (FIG. 2J). Positive correlations between VCN and IDS enzyme activity levels in BM, spleen, brain, lung, liver and heart, was observed with nearly equivalent activity/VON for both IDS and IDS.ApoEII, suggesting that enzyme overexpression is driven by increases in genome integration of the IDS gene (FIG. 2K).

(52) A value of 15.41 units/VON of enzyme activity was detected in LV.IDS.ApoEII compared to 2.56 units/VON in LV.IDS in plasma, suggesting that IDS enzyme activity in plasma is significantly increased by fusion of the ApoEII residue. This increase in enzyme activity in IDS.ApoEII is further demonstrated by comparing IDS enzyme activity to IDS protein in plasma, where IDS.ApoEII appears to be more active per unit of IDS protein (FIG. 2M).

(53) Lysosomal Homeostasis

(54) The dysfunction and uncontrolled accumulation of primary storage material in lysosomes in MPS II is likely to have a profound impact on lysosomal regulation and subsequent homeostasis. Importantly, neurodegeneration is associated with lysosomal dysfunction and impaired autophagy. In disease states such as MPS II, endogenous lysosomal enzymes can compensate for the deficiency of another lysosomal enzyme. Elevated levels of the lysosomal hydrolase β-hexosaminidase were detected in the plasma (2-fold over WT), spleen (1.53-fold over WT) and brain (2-fold over WT) of untreated MPS II animals (FIG. 2N-P). Plasma, spleen and brain levels of β-hexosaminidase were fully normalized back to WT levels in both LV.IDS- and LV.IDS.ApoEII-treated groups (FIG. 2N-P). WT-HSCT normalized β-hexosaminidase levels in plasma and spleen (FIG. 2N, 2O), and ameliorated levels in the brain without achieving complete normalization to WT levels (FIG. 2P).

(55) Heparan Sulfate Accumulation is Fully Normalized with LV.IDS.ApoEII but not LV.IDS

(56) HS and CS/DS glycosaminoglycans were purified from brain samples, and analysed and quantified by reverse-phase HPLC. A 6-fold increase in total HS was detected in brains of MPS II mice and mice treated with WT-HSCT (FIG. 6A). Mice treated with LV.IDS showed a decrease in total HS accumulation in the brain to approximately 3-fold of WT levels. Most importantly, LV.IDS.ApoEII-treated mice showed a complete normalization of brain HS levels back to WT levels and significantly lower levels of HS when compared to LV.IDS (FIG. 6A).

(57) HS composition analysis in MPS II mice showed that 31.1% of brain HS consisted of the fully sulfated UA(2S)-GlcNS(6S), compared to 12.3% in control WT mice (FIG. 6B). In WT mice, these generally form clusters with other sulfated disaccharides along the chain, with significant increases in sulphation along the entirety of the HS chain in MPS II mice. This trend was reversed with WT-HSCT, LV.IDS and most effectively by LV.IDS.ApoEII. Similarly, increases in UA(2S)-GlcNS from 16.8% in WT mice to 31.1% in MPSII mice were observed, and fully corrected down to 18.4% in the LV.IDS.ApoEII group only.

(58) It was also observed a significant reduction in total brain CS/DS levels in LV.IDS.ApoEII mice when compared to MPS II (Supplementary FIG. 2A); although no significant differences were detectable between WT and MPS II mice. increases in UA(2S)-GalNAc(4S) from 1.03% in WT mice to 6.5% in MPS II mice were detected, with complete correction obtained in the LV.IDS.ApoEII group.

(59) LV.IDS.ApoEII Corrects Lysosomal Accumulation in Neurons Throughout the Brain

(60) The effects of increased IDS enzyme levels in the brains of transplanted MPS II mice at 8 months of age (6 months post-transplant) on lysosomal enlargement and substrate accumulation in neurons (NeuN) using the lysosomal marker LAM P2 were then determined. WT animals displayed weak, punctate and perinuclear LAMP2 staining that only partially co-localized with NeuN in the motor cortex (layer V/VI). Untreated MPS II and WT-HSCT-treated animals displayed strong co-localized staining of NeuN and LAM P2 in the motor cortex, caudate putamen, hippocampus and amygdala, suggesting a heavy lysosomal burden in neurons or satellite glial cells (FIG. 6C). LV.IDS mediated improvements in the cerebral cortex, caudate putamen and amygdala, with engorged lysosomal compartments in the hippocampus still visible, suggesting only a partial correction of primary substrate accumulation, which strongly correlates to the levels of HS detected in the brain (FIG. 6A, 6B). LV.IDS.ApoEII fully normalised the increased LAMP2 staining in the cortex, caudate putamen and hippocampus, and considerably reduced the amount of lysosomal burden in the amygdala (FIG. 6C).

(61) LV.IDS.ApoEII Fully Normalizes Neuro-Inflammation Whilst LV.IDS Mediates an Improvement in MPS II Mice

(62) Astrocytes have been found to mediate a strong neuro-inflammatory response in MPS disorders, which translates into reactive gliosis, astrogliosis and increased levels of inflammatory cytokines. Brain coronal sections of control and treated MPS II mice were stained with the astrocytic marker GFAP (glial fibrillary associated protein; green) and LAMP2 (red). Significantly more GFAP staining was observed in untreated MPS II than in WT mice in the cortex, caudate putamen and amygdala, indicative of extensive astrogliosis (FIG. 7A). Additionally, strong co-localization of GFAP and LAMP2 was observed in the caudate putamen, hippocampus and amygdala in untreated and WT-HSCT mice (FIG. 7A), suggesting significant lysosomal substrate accumulation in astrocytes in addition to neurons (FIG. 6C). LV.IDS.ApoEII was able to fully abrogate astrogliosis and decrease LAMP2 staining back to WT levels in the cortex, caudate putamen, hippocampus and amygdala, correlating to decreases in substrate storage and inflammatory cytokines (FIG. 6A, 6B, 6A-D). Similarly, LV.IDS decreased the number of reactive astrocytes present in the cortex, caudate putamen and amygdala.

(63) LV.IDS.ApoEII Fully Corrects Cognitive Abnormalities and Coordination and Balance in MPS II Mice

(64) To understand whether CNS and skeletal phenotype in the MPS II mouse model could be ameliorated with LV.IDS- or LV.IDS.ApoEII-modified HSCs, functional studies of cognition and sensorimotor performance were performed at 8 months of age, equivalent to 6 months post-transplant, on all treated animals in each group. Cognitive evaluation of spatial working memory was evaluated using the Y-maze test, which exploits their innate preference to explore novel arms over recently explored arms over 10 minutes (as illustrated in FIG. 3a).

(65) Neurocognitive assessment showed complete normalisation of spontaneous alternation in LV.IDS.ApoEII-treated mice, but not in the LV.IDS-treated or WT-HSCT groups (FIG. 3b). This suggests not only complete correction of cognitive dysfunction seen in the MPS II mouse model using LV.IDS.ApoEII, but also shows the prevention of further cognitive deterioration associated with progressive MPS II disease. Interestingly, WT-HSCT has no positive impact on the cognitive symptoms associated with MPS II;

(66) further highlighting that WT-HSCT may not be suitable to treat the brain in MPS II. The total number of entries into the different arms of the Y-maze can also be used as a proxy measure of overall activity. No differences in the number of total entries were detected between all tested groups, suggesting a real phenotypic rescue of cognitive symptoms in LV.IDS.ApoEII-treated animals (as shown in FIG. 3c).

(67) Control and treated mice also underwent testing on the rotarod, a well-established test for sensorimotor coordination and balance in movement disorders in rodents (as shown in FIG. 3d). 8-months-old MPSII mice showed a reduction in performance on the accelerating rod as previously described. This was entirely rescued by all transplant treatments, including WT-HSCT (as shown in FIG. 3e).

(68) Neuro-Inflammatory Cytokines are Normalised with LV.IDS.ApoEII but not LV.IDS

(69) Cytometric bead arrays (CBA) were used to quantify a number of inflammatory cytokines associated with chronic neuro-inflammation from whole brain extracts of control and treated mice at 8 months of age. For the first time, we identified significant increases in macrophage inflammatory protein (MIP-1α/CCL3), interleukin 1α (IL-1α) protein, RANTES (CCL5) and monocyte chemoattractant protein (MCP-1/CCL2) in untreated MPS II animals (as shown in FIGS. 4a, 4b, 4c, 4d). MIP-1α, IL-1α and RANTES protein levels were normalised with LV.IDS.ApoEII, and only partially with LV.IDS, and MCP-1 levels remained elevated for all groups (as shown in FIG. 4b).

(70) Additionally, we observed a 30-fold and 25-fold increase in isolectin B4 (ILB4)-positive cells in the cortex and striatum of untreated MPS II mice, respectively (FIG. 4E, 4F, 4G), suggesting extensive activation of microglia and subsequent neuro-inflammation. Interestingly, both WT-HSCT and LV.IDS reduced ILB4 staining to 14-fold and 12-fold of WT levels in the cortex (FIG. 4F), and to 15-fold and 13-fold of WT staining in the striatum (FIG. 4G), respectively. Most importantly, LV.IDS.ApoEII was able to completely normalize the number of activated microglia in both the cortex and striatum (FIG. 4F, 4G), which strongly correlates with the reduction of neuro-inflammation cytokines previously observed and the full abrogation of astrocytosis in LV.IDS.ApoEII.

(71) Overall, this suggests that the release of neuro-inflammatory cytokines and chemokines, reactive astrogliosis and microglial activation in MPS II can be fully abrogated by LV.IDS.ApoEII, and only partially with LV.IDS.

(72) Heparan Sulphate Accumulation is Fully Normalised with LV.IDS.ApoEII but not LV.IDS

(73) HS GAGs were purified from control and treated brains of MPS II mice and depolymerised into individual HS disaccharides using bacterial heparinase enzymes followed by fluorescent-tagging of reducing ends of individual disaccharides using AMAC. Reverse-phase HPLC separation was used to quantify and determine the individual contributions and sulphation patterns of each HS disaccharide.

(74) HPLC analysis allows for the relative levels of total HS to be calculated between WT, untreated MPS II and all treatment groups (as shown in FIG. 4e). A 6-fold increase in total HS was detected in brains of MPS II mice and mice treated with WT-HSCT (p<0.0001). Interestingly, mice treated with LV.IDS showed a decrease in total HS accumulation in the brain to approximately 3-fold of WT levels. Most importantly, LV.IDS.ApoEII-treated mice showed a complete normalisation of brain HS levels back to WT levels (as shown in FIG. 4e).

(75) HS composition analysis showed significant increases of tri-sulphated disaccharide UA(2S)-GlcNS(6S), and increases in UA(2S)-GlcNS in untreated MPS II brains (as shown in FIG. 4f). This trend was partially reversed with WT-HSCT and LV.IDS, although full correction back to WT levels was only obtained in the LV.IDS.ApoEII group.

(76) Mono-sulphated HS disaccharides showed a significantly different trend; where untreated MPS II and WT-HSCT-treated levels of UA-GlcNS were lower than in WT brains (as shown in FIG. 4f). This was partially improved with the LV.IDS treatment, but only fully corrected in the LV.IDS.ApoEII group.

(77) Skeletal Pathology is Ameliorated by all Transplant Strategies in MPS II Mice

(78) Total body X-rays under full anaesthesia were performed on control and treated mice to obtain robust data on the extent of skeletal symptoms in the MPS II mouse model. Widths of zygomatic arches and appendicular long bones (humeri and femurs) were measured using ImageJ imaging software.

(79) The width of the zygomatic arches, which are significantly increased in untreated MPS II animals, were reduced to WT dimensions in all transplanted groups, including WT-HSCT (as shown in FIGS. 5a, 5b). Humerus widths were significantly reduced in WT-HSCT and LV.IDS groups, although full correction was only obtained in the LV.IDS.ApoEII-treated animals (as shown in FIG. 5c). Moreover, femur widths in all treated animals showed no significant differences when compared to WT animals, suggesting significant skeletal rescue.

(80) Peripheral Inflammation is Abrogated Following Transplantation of WT, LV.IDS- or LV.IDS.ApoEII-Modified HSCs

(81) Elevated levels of MCP-1, MIP-1α and RANTES were detected in the livers of MPS II mice at 8 months of age, which were completely abrogated by WT-HSCT, LV.IDS- or LV.IDS.ApoEII treatments (FIG. 5E-5G). These data suggest that WT-HSCT, LV.IDS and LV.IDS.ApoEII produce sufficient amounts of peripheral enzyme to fully correct chronic peripheral inflammation in MPS II mice.

(82) Gene Expression of Heart Failure Markers Nppb and Myh7 are Normalized in WT-HSCT, LV.IDS and LV.IDS.ApoEII Groups

(83) The expression of Nppb and Myh7, two markers associated with cardiomyopathies and cardiac pathology, which could be indicators of higher risks of heart failure in the MPS II mouse model, were investigated. The expression of Nppb, which encodes for the brain natriuretic peptide (BNP) that is secreted from the ventricles and regulates myocyte stretching and blood pressure, was found to be approximately 16-fold higher in MPS II than in WT male mice (FIG. 5H). Nppb expression was fully stabilized back to WT levels in WT-HSCT, LV.IDS and LV.IDS.ApoEII groups (FIG. 5H). Myh7 expression, primarily found in embryonic heart and encodes for myosin heavy chain beta as a key component of cardiac muscle and type I muscle fibers, was elevated in untreated MPS 11 animals. Myh7 expression in WT-HSCT, LV.IDS and LV.IDS.ApoEII groups was similar to WT expression (FIG. 5I).

(84) Overexpression of IDS Following Transplantation of LV.IDS and LV.IDS.ApoEII-Transduced HSCs does not Yield an Immune Response to Human IDS

(85) To study whether gene-modified cells were able to mediate tolerance to human IDS post-transplant, we analysed plasma from mice that received full myeloablative conditioning followed by either LV.IDS or LV.IDS.ApoEII transplant, both over-expressing human IDS, for IgG antibodies against human IDS. Overall IDS-specific IgG titers in LV.IDS and LV.IDS.ApoEII groups remained in the normal range and did not contribute to an immune response to the enzymes (FIG. 5J).

(86) LV.IDS.ApoEII Treatment Acts Through Multiple Mechanisms

(87) Following the observed increase in enzyme activity in plasma and the increased enzyme activity per VCN in LV.IDS.ApoEII-treated mice (FIG. 2f, 2j), we hypothesized that the circulation time of enzyme might be increased. Equivalent levels of IDS and IDS.ApoEII enzyme were injected into MPS II mice and protein levels monitored by ELISA (FIG. 9A). Interestingly, enzyme clearance rate, whether from degradation or uptake into organs, was similar between the IDS and IDS.ApoEII groups and was effectively cleared in both groups by 30 minutes.

(88) Next levels of active enzyme in the plasma compared to total IDS protein were compared and measured by ELISA, hypothesizing that the conformation of the enzyme may be altered with the addition of the ApoEII residue, conferring additional protection against degradation. IDS.ApoEII appeared to be more active per unit of IDS protein in plasma (FIG. 9B). This may suggest the active site of native IDS enzyme is rapidly degraded in plasma whereas the ApoEII addition is protective, effectively prolonging enzyme activity in vivo.

(89) The BBB endothelial cell line bEND.3 was used to determine whether there was any difference in enzyme uptake by endothelial cells. These cells produce an effective BBB layer in transwells (FIG. 9C) and express both LDLR and LDLR-related protein 1 (LRP1) receptors (FIG. 9D, 9E). In order to ensure that each enzyme has a similar M6P status to that of the HSCGT produced enzyme, we used IDS and IDS.ApoEII enzyme secreted into the media after transfection of CHME3 human microglial cells and standardized by ELISA. In monolayer culture, we compared the uptake of IDS versus IDS.ApoEII into bEND.3 cells, identifying a 4.7-fold increase in cellular uptake with the addition of the ApoEII peptide (FIG. 9F). The uptake and transcytosis of IDS or IDS.ApoEII across polarized cell layers of bEND.3 endothelial cells in transwells to mimic the BBB were then compared. 2.6-fold increases in uptake were apparent, similar to when cells were grown in monolayer, together with a 1.5-fold increase in transcytosis to the basolateral side of the transwell (FIG. 9G, 9H).

(90) In addition, blockade of ApoE dependent receptors using ApoE or blockage of M6P receptors using M6P (FIG. 9I), revealed that IDS.ApoEII was preferentially and unexpectedly taken up via M6P receptors, although blockade with ApoE peptide also significantly inhibited uptake of IDS.ApoEII by approximately 30%. The ApoEII peptide sequence also codes for a HS site, required as a co-receptor for receptor/ligand binding of ApoE to its receptors, including LDLR and LRP1 (Ji et al, 1993). Heparinase pre-treatment of cells also resulted in a reduction in IDS.ApoEII uptake by approximately 30%, similar to results with ApoE peptide, suggesting that ApoE/HS may also be important in uptake and transcytosis across bEND3 cells.

Discussion

(91) The addition of the linker and ApoEII peptide did not change the expression, production or secretion of the IDS enzyme in vitro, but produced supra-physiological levels of IDS enzyme in transduced HSCs using both LV.IDS and LV.IDS.ApoEII vectors for similar vector copy number. Complete engraftment of CD45.1+ donor cells (>80%) was obtained using full myelo-ablative conditioning using busulfan in all transplanted animals, with no significant differences in downstream in vitro differentiation assays at the time of transplant (data not shown).

(92) Surprisingly, IDS enzyme activity levels in plasma in the LV.IDS.ApoEII group were approximately 3-fold higher than in LV.IDS, even with lower VCN in WBCs. This translates to higher enzyme activity per copy in the LV.IDS.ApoEII group, suggesting that the ApoEII residue stabilizes or improves activity by changing its conformation, and appear to provide a protective effect against enzyme inactivation, but not clearance in plasma (FIG. 8). A higher uptake of IDS.ApoEII in bEND.3 cells compared to unmodified IDS was detected and this was believed to be mediated predominantly by M6PR. The receptor-binding portion of apoE used in the IDS.ApoEII fusion enzyme (residues 142-147) is able to form a high affinity binding complex with an octasaccharide HS fragment composed of four repeats of UA(2S)-GlcNS(6S), which are abundant on endothelial cell surfaces and even more abundant in MPS II. HS typically acts as a co-receptor in many receptor ligand interactions and increased binding to HS proteoglycans (HSPG) through ApoEII could mediate an increase in cellular uptake through the LDLR, LDLR-related protein 1 (LRP1), M6P or by direct uptake of an apoE-HSPG complex.

(93) Similar amounts of enzyme activity within the brain between the LV.IDS and LV.IDS.ApoEII groups were detected, but complete correction only in LV.IDS.ApoEII with improved clearance of LAM P2 from neurons and astrocytes. One explanation for this is that enzyme uptake from the interstitial space may be more efficient using IDS.ApoEII, thereby correcting resident brain cells much more effectively than unmodified IDS whilst maintaining the same overall levels (FIG. 8).

(94) Full correction of primary storage elevations and a global normalisation of the sulphation patterning, which plays a major role in neuro-inflammation, were observed in LV.IDS.ApoEII-treated animals. Partial correction of the primary HS storage in the brain is insufficient to correct cognitive behavior. The accumulation of HS in MPS II likely could provide one of the first signals that trigger neuro-inflammation and exacerbate neurodegeneration. The sulphation patterning also plays a crucial role in cellular function and HS-binding homeostasis, as 6-O- and 2-O-sulphated HS are essential for signaling of fibroblast growth factor and stromal cell derived factor-1 (CXCL12). Indeed, abnormal excess HS in MPS I was shown to reduce migration of HSCs under limiting conditions via sequestration of CXCL12 (42). In the context of this study, increases in sulfated disaccharides in brain tissue of diseased animals could promote improved cellular uptake of the IDS.ApoEII enzyme, thereby enhancing enzyme targeting to diseased cells.

(95) A significantly increased uptake of IDS.ApoEII in bEND.3 cells compared to IDS via both an ApoE/HS based mechanism and via M6P receptors was observed. The use of multiple targeting mechanisms could mediate more efficient targeting to enzyme-deficient cells throughout the body as well as across the BBB. The receptor-binding portion of ApoE used here is able to form a high affinity binding complex with an octasaccharide HS fragment composed of four repeats of UA(2S)-GlcNS(6S), which are abundant on endothelial cell surfaces and even more abundant in MPS II. In the context of this study, increases in sulfated disaccharides in brain tissue of diseased animals could promote improved cellular uptake of the IDS.ApoEII enzyme, via the HS binding motif in the ApoEII peptide, thereby enhancing enzyme targeting to diseased cells. HS typically acts as a co-receptor in many receptor ligand interactions and increased binding to HS proteoglycans through ApoEII could mediate an increase in cellular uptake through the LDLR, LRP1, M6P or by direct uptake of an ApoE-HSPG complex. Improved plasma stability coupled with increased BBB uptake and transcytosis could together account for the normalization of HS and DS storage, as well as several other neuropathologies in the brain seen with LV.IDS.ApoEII, in the absence of significant differences in brain enzyme amount. A similar effect of increased uptake, clearance and cell association for similar enzyme activities have been seen in MPS IIIB and Pompe disease using enzymes coupled to GILT tags targeting an alternative epitope of M6P via an IGFII receptor directed peptide. In this study small increases in brain enzyme activity with SGSH.ApoB was shown with no significant changes over native IDS.

(96) Neuro-inflammation is commonly reported in LSDs, likely caused by the accumulation of various undegraded molecules, which cooperatively activate and perpetuate a neuro-inflammatory milieu that may exacerbate the disease itself. MPS II mice elicit a strong inflammatory response in the brain, with elevated levels of MIP-1α, IL-1α, RANTES and MCP-1. MIP-1α, IL-1α and RANTES levels were fully normalised in the LV.IDS.ApoEII group, with only partial decreases in LV.IDS-treated mice. Interestingly, MCP-1 levels remained elevated in MPS II and all busulfan-conditioned mice. As we have previously shown, busulfan-conditioning leads to long-term increases in MCP-1 levels in the brain, a key mediator of cell transmigration to the CNS, and exerts a long-term trans-migratory effect. Approximately 20% of intravenously injected busulfan can cross the BBB, driving an even stronger pro-migratory MCP-1 response, which may ultimately facilitate the transmigration of donor-derived leukocytes across the BBB into the CNS in MPS II mice and provide additional means of trafficking enzyme into brain parenchyma.

(97) Microglial activation and astrocytosis are commonly reported in MPS disorders, including this study. We observed a complete abrogation of GFAP and LAMP2 staining in the cortex, caudate putamen, hippocampus and amygdala of LV.IDS.ApoEII mice, with only partial correction of the same areas in the LV.IDS group. Furthermore, complete normalisation of activated microglia was observed in the cortex and striatum of LV.IDS.ApoEII-treated mice, with only a 50% reduction in LV.IDS. LV.IDS.ApoEII treatment is comparable to the correction of astrogliosis and microglial activation reported using direct AAV9-IDS injection into the CSF (15). Peripheral inflammation was detected in livers of MPS II mice, with stark elevations in the levels of MCP-1, MIP-1α and RANTES, and was abrogated by all transplants, indicating that peripheral IDS enzyme levels obtained with an allogeneic transplant can mediate a reduction in inflammation in the periphery.

(98) As a sensitive and widely accepted paradigm of exploratory behavior and spatial working memory, the Y-maze accounts for potential physical impairments in MPS II mice, unlike the Barnes maze, which may be invalidated by differential physical performance. Full behavioural correction of cognitive deficits was observed in the LV.IDS.ApoEII group alongside normalisation of coordination and balance. We hypothesise that cognitive improvements likely stems from a combination of factors; a reduction in primary storage of HS alongside full abrogation of chronic neuro-inflammation, astrogliosis and microglial activation, all of which were only observed in LV.IDS.ApoEII-treated animals. The rescue of coordination and balance can be attributed to either central or peripheral rescue, or a combination thereof. Most importantly, this further highlights that the addition of the ApoE tandem peptide is absolutely necessary to target IDS enzyme to the brain to provide a full correction of the neurocognitive aspect in MPS II mice.

(99) The present inventors and others have reported progressive skeletal abnormalities in the MPS II mouse model, such as enlargement of craniofacial bone structures and femurs), correlating with the dysostosis multiplex seen in MPS II patients. As little enzyme is targeted to the cartilage or bone lesions, ERT using idursulfase showed limited benefits in joint pain, stiffness, or range of motion, although earlier treatments could provide benefits. In our study, the widths of zygomatic arches, humerus and femurs were significantly reduced in all transplanted animals, including WT-HSCT, suggesting that some level of enzyme can penetrate bone tissue if treated at an early time point when skeletal phenotype remains mild. This is partly comparable to liver-directed AAV2/8TBG-IDS gene therapy, where craniofacial abnormalities were also corrected. Importantly, it is likely that sustained availability of enzyme to the skeleton and joints from an early time point is required for clinical improvements.

(100) Cardiac involvement in MPS II ranges from progressive valvular pathology, left ventricular hypertrophy, increased wall thickness to systemic hypertension, yielding a complex cardiac phenotype that remains difficult to treat (49). A plethora of factors can trigger the activation of transcription factors, co-regulators and microRNAs that will alter cardiac gene expression. HS GAGs also partly regulate Sonic Hedgehog (Shh), involved in heart ontogenesis and cardiac regeneration, which is downregulated alongside Ptch1, FoxM1 and Bmp4 in MPS II mice. Expression of Nppb and Myh7, two genes previously implicated with heart failure in MPS IIIB mice, was elevated up to 18-fold and 9-fold over WT levels respectively, suggesting a significant deregulation of cardiac genes and cardiac pathways in MPS II mice that is rescued with all transplants. Hence, sustained delivery of IDS enzyme in the periphery can benefit heart tissue and restore normal cardiac gene expression, if only partially. Overall, it has been shown for the first time that the expression of cardiac genes involved in heart failure can be modulated to WT levels by transplanting HSCs expressing either endogenous or supra-physiological levels of IDS enzyme, and that this may be a significant step in treating the cardiorespiratory phenotype in MPS II patients.

(101) Immunologically foreign proteins and enzymes such as ERT can trigger the release of inhibitory antibodies that may decrease therapeutic efficacy, although molecular and cellular chimerism after HSCT can induce tolerance to donor-specific antigens. IgG antibodies against human recombinant IDS in plasma of LV.IDS and LV.IDS.ApoEII-treated mice were not detected, and no adverse symptoms identified that could be attributed to neutralising antibodies. Overall, this is a strong indication that hematopoietic stem cell gene therapy (HSCGT) can induce tolerance and that both enzymes produced are well tolerated by the immune system. Lastly, the addition of the ApoEII peptide residue does not generate increased immune sensitivity when compared to unmodified IDS.

(102) Significantly, the addition of the apoE tandem repeat to human IDS allows for complete correction of the neuro-inflammation, neurodegeneration and cognitive behaviour in the MPS II mouse model, likely by a combination of increased uptake and enzyme stabilisation mechanisms. Previous gene therapy approaches have highlighted the therapeutic potential of BBB-fusion enzymes with the receptor-binding domain of other Apo complexes such as ApoB and ApoE to correct brain pathology in disease models of LSDs and their promising clinical use for MPS disorders. This is the first study highlighting the combined use of HSCGT and the ApoEII-fusion enzyme to fully correct the neurological, skeletal, inflammatory and behavioural phenotypes in MPS II mice. The experiments show the suitability HSCGT using ApoEII-modified enzyme for the treatment of MPS II patients.

(103) The forgoing embodiments are not intended to limit the scope of the protection afforded by the claims, but rather to describe examples of how the invention may be put into practice.

(104) Sequence Listings

(105) TABLE-US-00001 (coIDS DNA sequence) SEQ ID No. 1 atgcctccac ctagaactgg aagaggcctg ctgtggctgg gcctggtgct gtctagtgtg   60 tgtgtggccc tgggcagcga gacacaggcc aacagcacaa ccgacgccct gaacgtgctg  120 ctgatcatcg tggacgacct gaggcctagc ctgggctgct acggcgataa gctcgtgcgg  180 agccccaaca tcgatcagct ggcctctcac agcctgctgt tccagaacgc attcgcacag  240 caggcagtgt gcgcccccag cagagtgtct ttcctgaccg gcagaaggcc cgacaccacc  300 cggctgtacg acttcaacag ctactggcgg gtgcacgccg gcaacttcag caccatcccc  360 cagtacttca aagaaaacgg ctacgtgacc atgagcgtgg gcaaggtgtt ccaccccggc  420 atcagctcca accacaccga cgacagcccc tacagctggt ccttcccacc ctaccacccc  480 agcagcgaga agtacgagaa caccaagacc tgcagaggcc ccgacggcga gctgcatgcc  540 aatctgctgt gccccgtgga cgtgctggat gtgcctgagg gaaccctgcc cgacaagcag  600 tctaccgagc aggccattca gctgctggaa aagatgaaga ccagcgccag ccccttcttc  660 ctggccgtgg gctatcacaa gccccacatc cctttcagat accccaaaga gttccagaag  720 ctgtaccccc tggaaaacat caccctggcc cccgatcctg aggtgccaga tggactgcct  780 cccgtggcct acaacccctg gatggacatc cggcagcgcg aggatgtgca ggccctgaat  840 atcagcgtgc cctacggccc catccccgtg gatttccagc ggaagatccg gcagagctac  900 ttcgccagcg tgtcctacct ggacacccaa gtgggcagac tgctgagcgc cctggacgat  960 ctgcagctgg ccaactccac catcattgcc ttcaccagcg accacggctg ggccctggga 1020 gaacatggcg agtgggccaa gtacagcaac ttcgacgtgg ccacccacgt gcccctgatc 1080 ttctacgtgc caggcagaac cgccagcctg cctgaggctg gcgagaagct gttcccttac 1140 ctggacccct tcgacagcgc ctcccagctg atggaacctg gcagacagag catggacctg 1200 gtggaactgg tgtccctgtt ccccacactg gccggactgg ctggactgca ggtgccccct 1260 agatgtcccg tgcctagctt tcacgtggaa ctgtgcagag agggcaagaa cctgctgaag 1320 cacttccggt tccgggacct ggaagaagat ccctacctgc ccggcaaccc cagagagctg 1380 atcgcctaca gccagtaccc cagacccagc gacatccctc agtggaacag cgacaagccc 1440 agcctgaagg acatcaagat catgggctac agcatccgga ccatcgacta ccggtacacc 1500 gtgtgggtgg gattcaaccc cgacgagttc ctggccaatt tctccgacat ccacgccggg 1560 gagctgtact tcgtggacag cgatcccctg caggaccaca acatgtacaa cgacagccag 1620 ggcggcgacc tgttccagct gctgatgccc 1650 (Wild Type IDS DNA Sequence) SEQ ID No. 2 atgccgccac cccggaccgg ccgaggcctt ctctggctgg gtctggttct gagctccgtc   60 tgcgtcgccc tcggatccga aacgcaggcc aactcgacca cagatgctct gaacgttctt  120 ctcatcatcg tggatgacct gcgcccctcc ctgggctgtt atggggataa gctggtgagg  180 tccccaaata ttgaccaact ggcatcccac agcctcctct tccagaatgc ctttgcgcag  240 caagcagtgt gcgccccgag ccgcgtttct ttcctcactg gcaggagacc tgacaccacc  300 cgcctgtacg acttcaactc ctactggagg gtgcacgctg gaaacttctc caccatcccc  360 cagtacttca aggagaatgg ctatgtgacc atgtcggtgg gaaaagtctt tcaccctggg  420 atatcttcta accataccga tgattctccg tatagctggt cttttccacc ttatcatcct  480 tcctctgaga agtatgaaaa cactaagaca tgtcgagggc cagatggaga actccatgcc  540 aacctgcttt gccctgtgga tgtgctggat gttcccgagg gcaccttgcc tgacaaacag  600 agcactgagc aagccataca gttgttggaa aagatgaaaa cgtcagccag tcctttcttc  660 ctggccgttg ggtatcataa gccacacatc cccttcagat accccaagga atttcagaag  720 ttgtatccct tggagaacat caccctggcc cccgatcccg aggtccctga tggcctaccc  780 cctgtggcct acaacccctg gatggacatc aggcaacggg aagacgtcca agccttaaac  840 atcagtgtgc cgtatggtcc aattcctgtg gactttcagc ggaaaatccg ccagagctac  900 tttgcctctg tgtcatattt ggatacacag gtcggccgcc tcttgagtgc tttggacgat  960 cttcagctgg ccaacagcac catcattgca tttacctcgg atcatgggtg ggctctaggt 1020 gaacatggag aatgggccaa atacagcaat tttgatgttg ctacccatgt tcccctgata 1080 ttctatgttc ctggaaggac ggcttcactt ccggaggcag gcgagaagct tttcccttac 1140 ctcgaccctt ttgattccgc ctcacagttg atggagccag gcaggcaatc catggacctt 1200 gtggaacttg tgtctctttt tcccacgctg gctggacttg caggactgca ggttccacct 1260 cgctgccccg ttccttcatt tcacgttgag ctgtgcagag aaggcaagaa ccttctgaag 1320 cattttcgat tccgtgactt ggaagaggat ccgtacctcc ctggtaatcc ccgtgaactg 1380 attgcctata gccagtatcc ccggccttca gacatccctc agtggaattc tgacaagccg 1440 agtttaaaag atataaagat catgggctat tccatacgca ccatagacta taggtatact 1500 gtgtgggttg gcttcaatcc tgatgaattt ctagctaact tttctgacat ccatgcaggg 1560 gaactgtatt ttgtggattc tgacccattg caggatcaca atatgtataa tgattcccaa 1620 ggtggagatc ttttccagtt gttgatgcct 1650 (ApoE tandem repeat (ApoEII) DNA Sequence) SEQ ID No. 3 ctgagaaagc tgcggaagcg gctgctgctg aggaagctga gaaaaagact gctg   54 (Linker DNA Sequence) SEQ ID No. 4 ctgggagggg gaggatctgg cggaggcgga agtggcggcg gaggatcagg gggcggaggc   60 tct   63 (coIDS Amino Acid Sequence) SEQ ID No. 5 MPPPRTGRGL LWLGLVLSSV CVALGSETQA NSTTDALNVL LIIVDDLRPS LGCYGDKLVR   60 SPNIDQLASH SLLFQNAFAQ QAVCAPSRVS FLTGRRPDTT RLYDFNSYWR VHAGNFSTIP  120 QYFKENGYVT MSVGKVFHPG ISSNHTDDSP YSWSFPPYHP SSEKYENTKT CRGPDGELHA  180 NLLCPVDVLD VPEGTLPDKQ STEQAIQLLE KMKTSASPFF LAVGYHKPHI PFRYPKEFQK  240 LYPLENITLA PDPEVPDGLP PVAYNPWMDI RQREDVQALN ISVPYGPIPV DFQRKIRQSY  300 FASVSYLDTQ VGRLLSALDD LQLANSTIIA FTSDHGWALG EHGEWAKYSN FDVATHVPLI  360 FYVPGRTASL PEAGEKLFPY LDPFDSASQL MEPGRQSMDL VELVSLFPTL AGLAGLQVPP  420 RCPVPSFHVE LCREGKNLLK HFRFRDLEED PYLPGNPREL IAYSQYPRPS DIPQWNSDKP  480 SLKDIKIMGY SIRTIDYRYT VWVGFNPDEF LANFSDIHAG ELYFVDSDPL QDHNMYNDSQ  540 GGDLFQLLMP  550 (Wild Type IDS Amino Acid Sequence) SEQ ID No. 6 MPPPRTGRGL LWLGLVLSSV CVALGSETQA NSTTDALNVL LIIVDDLRPS LGCYGDKLVR   60 SPNIDQLASH SLLFQNAFAQ QAVCAPSRVS FLTGRRPDTT RLYDFNSYWR VHAGNFSTIP  120 QYFKENGYVT MSVGKVFHPG ISSNHTDDSP YSWSFPPYHP SSEKYENTKT CRGPDGELHA  180 NLLCPVDVLD VPEGTLPDKQ STEQAIQLLE KMKTSASPFF LAVGYHKPHI PFRYPKEFQK  240 LYPLENITLA PDPEVPDGLP PVAYNPWMDI RQREDVQALN ISVPYGPIPV DFQRKIRQSY  300 FASVSYLDTQ VGRLLSALDD LQLANSTIIA FTSDHGWALG EHGEWAKYSN FDVATHVPLI  360 FYVPGRTASL PEAGEKLFPY LDPFDSASQL MEPGRQSMDL VELVSLFPTL AGLAGLQVPP  420 RCPVPSFHVE LCREGKNLLK HFRFRDLEED PYLPGNPREL IAYSQYPRPS DIPQWNSDKP  480 SLKDIKIMGY SIRTIDYRYT VWVGFNPDEF LANFSDIHAG ELYFVDSDPL QDHNMYNDSQ  540 GGDLFQLLMP  550 (ApoE tandem repeat (ApoEII) Amino Acid Sequence) SEQ ID No. 7 LRKLRKRLLL RKLRKRLL   18 (Linker Amino Acid Sequence) SEQ ID No. 8 LGGGGSGGGG SGGGGSGGGG S   21

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